Pilot Study Comparing Multi-family Therapy to Single Family Therapy ...

RESEARCH ARTICLE

Pilot Study Comparing Multi-family Therapy to Single Family Therapy for Adults with Anorexia Nervosa in an Intensive Eating Disorder Program Gina Dimitropoulos1,2*, Jamie C. Farquhar2, Victoria Emily Freeman2, Patricia Anne Colton2,3 & Marion Patricia Olmsted2,3 1

Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada Eating Disorders Program, University Health Network, Toronto, Ontario, Canada 3 Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada 2

Abstract Multi-family therapy (MFT) has yet to be evaluated in families of adults with anorexia nervosa (AN). The study aims were: (i) assess the feasibility of MFT for AN; and, (ii) assess whether MFT is associated with improved outcomes for families compared with single-family therapy (SFT). Adult patients with AN consecutively referred to an eating disorder treatment program were assigned (non-randomly) to receive eight sessions of SFT or MFT. Assessment occurred pre-therapy, immediately post-therapy, and at 3-month follow-up. A total of 37 female patients (13 SFT, 24 MFT) and 45 family members (16 SFT, 29 MFT) completed treatment. There were significant time effects for patients’ BMI, eating disorder-related psychopathology and multiple family outcome measures. There were no differences between MFT and SFT on family outcome measures at end of treatment and 3 months post treatment. MFT is a feasible intervention that can be used in adult intensive treatment for those with AN. Copyright © 2015 John Wiley & Sons, Ltd and Eating Disorders Association. Keywords family therapy; multi-family therapy; single-family therapy; eating disorders; adult anorexia nervosa *Correspondence Gina Dimitropoulos, Eating Disorders Program, University Health Network, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada. Tel: (416) 340-3749; Fax: (416) 340-4198. Email: gina.dimitropoulos@uhn.ca Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/erv.2359

Anorexia nervosa (AN) is a serious mental illness with a high rate of mortality and morbidity (Smink, van Hoeken, & Hoek, 2012), as well as a frequently chronic clinical course (Hay, Touyz, & Sud, 2012; Treasure, Stein, & Maguire, 2014). Individuals with AN are often confronted with stigmatizing attitudes from the general public who may view the eating disorder behaviours as volitional (Crisp, Gelder, Rix, Meltzer, & Rowlands, 2000; Stewart, Keel, & Schiavo, 2006). Fear of being stigmatized may heighten the reliance of individuals with AN on their immediate families for instrumental support. The over-reliance on families for support may contribute to duress in families who may lack sufficient skills to effectively intervene to assist the affected individual. Family members caring for an adult with AN may experience many challenges, including psychological duress, social isolation, stigma, and poor family functioning (Dimitropoulos, Carter, Schachter, & Woodside, 2008; Highet, Thompson, & King, 2005). The strain of caring for someone with AN contributes to high rates of anxiety and depression in family members (Kyriacou, Treasure, & Schmidt, 2008; Zabala, Macdonald, & Treasure, 2009), which may intensify their propensity to overprotect the affected individual (Clemency & Rayle, 2006; Whitney & Eisler, 2005; Whitney et al., 2005). Negative feelings and criticism may be increased in the family members when the Eur. Eat. Disorders Rev. (2015) © 2015 John Wiley & Sons, Ltd and Eating Disorders Association.

person with the illness is ambivalent to engage in treatment. Emotional over-involvement, accommodation, and criticism from family members may unwittingly reinforce the attitudes and behaviours in the affected person that they are trying to change (Kyriacou et al., 2008). The general public is more likely to blame families for causing AN compared with other mental illnesses such as schizophrenia.11 Concerns and fears that their loved one will be discriminated against have been shown to result in family members of individuals with other mental illnesses withdrawing from their own social support network (Gonzalez et al., 2007; Lee et al., 2006; Shibre et al., 2001; Östman & Kjellin, 2002; Stengler-Wenzke, Trosbach, Dietrich, & Angermeyer, 2004; Wahl & Harman, 1989). Qualitative studies demonstrate that family members would value the opportunity to share their struggles with others who are in the same predicament (Haigh & Treasure, 2003; Graap et al., 2008; Whitney et al., 2005; Winn, Perkins, Murray, Murphy, & Schmidt, 2004). Hence, there is a great need for interventions which target social isolation and stigma in family members of adults with AN. Guided by the cognitive–interpersonal maintenance model of AN (Schmidt & Treasure, 2006; Treasure & Schmidt, 2013), various interventions have been developed and systemically evaluated

G. Dimitropoulos et al.

Multi-Family Therapy for Anorexia Nervosa

for family members of adults with AN, using a variety of formats including collaborative care skills workshops (Pépin & King, 2013; Rhind et al., 2014; Sepulveda, Lopez, Macdonald, & Treasure, 2008; Treasure, Whitaker, Todd, & Whitney, 2012), DVD accompanied by telephone clinical support (Sepulveda et al., 2008), and a web-based intervention (Overcoming Anorexia Online; Grover et al., 2011). Based on the cognitive–interpersonal maintenance model, specific constructs are targeted in the above interventions, including the impact of the illness on the family, family member distress, emotional over-involvement, and high levels of expressed emotion. Expressed emotion is a term that is used to describe the emotionally based interactions between the affected individual and their family member (Hooley, 2007). Research demonstrates that these interventions are effective at reducing caregiver distress, decreasing the perceived adverse effects of the illness on the family and expressed emotion levels, and increasing the acquisition of knowledge about the illness (Goddard et al., 2011; Pépin & King, 2013; Sepulveda et al., 2008; Sepulveda et al., 2010). Multi-family therapy, which involves multiple families and individuals affected by mental illnesses including AN, is a potential alternative to the caregiver workshop (which includes only family members). Preliminary qualitative data on studies evaluating MFT in adolescents with AN reveals that participants report improvements in family climate, including increased emotional support and reductions in tensions (Dare & Eisler, 2000; Eisler, 2005; Scholz, Rix, Scholz, Gantchev, & Thömke, 2005). MFT has been widely employed and shown to be effective with families of individuals affected with mental illnesses including depression, bipolar disorder, and schizophrenia (Dyck et al., 2000; Hellemans et al., 2011; Lemmens, Eisler, Migerode, Heireman, & Demyttenaere, 2007; Lemmens, Eisler, Buysse, Heene, & Demyttenaere, 2009; Madigan et al., 2012; Solomon, Keitner, Ryan, Kelley, & Miller, 2008). In a recent review of empirical evidence regarding psychoeducation and multi-family therapy groups, Lyman et al. (2014) stated that ‘research under-scores the power of bringing families together to support each other and share their experience and knowledge (pg. 425)’. These authors also proposed that groups help to reduce perceived stigma by bringing families together. Despite the theoretical underpinnings of MFT, there is an absence of research to confirm that this intervention reduces stigma and increases social support. Outcome measures chiefly consist of symptom reduction and medication adherence for the affected individual; measured outcomes for family members predominantly include quality of life, psychological distress, and expressed emotion. MFT may be particularly acceptable in a typical adult eating disorder program that prohibits clinician contact with family members without the written legal consent of the individual with the eating disorder, as all family-clinician communication is in collaboration with, and in the presence of the patient. Various clinical guidelines and charters have been established emphasizing the fundamental right of family members to have access to resources, information, and support required to assist their loved one with AN (Academy for Eating Disorders, 2006; Le Grange, Lock, Loeb, & Nicholls, 2010). However, clinicians working with adults must balance the needs of family members with the rights of individuals with AN to confidentiality, privacy, and choice as to whom to involve in their care. Research points to the importance of empowerment, autonomy, and an internal

locus of control for individuals with eating disorders (Espíndola & Blay, 2013; Darcy et al., 2010; Hay et al., 2012; Nordbø et al., 2012). The need for autonomy means that it is extremely important to ensure that individuals with AN decide whether or not to involve their families in treatment. A fear of their autonomy being threatened may partly explain their reluctance in some cases to involve their families in treatment (Schmidt et al., 2007; Slater, Treasure, Schmidt, Gilchrist, & Wade, 2014). However, research shows that family support, compassion, feeling understood, and appropriate involvement from family are paramount during treatment and the recovery process (Kaap-Deeder et al., 2014; Kelly & Carter, 2014). In the current pilot study, we compare multi-family therapy to single family therapy (treatment as usual). Our first aim was to examine the feasibility of delivering MFT to people with AN in an intensive eating disorder program and their family members. We predicted that MFT would be a feasible and acceptable option. A second aim of this study was to gather preliminary evidence that MFT would improve outcomes for family members. Based on previous findings on caregiver workshops, we hypothesized that in contrast to those in SFT, families participating in MFT would experience reductions in the adverse impact of the illness on the family, expressed emotion and psychological distress in family members. Third, given that the psychoeducational material in MFT directly challenges perceived stigma and blame towards both individuals with AN and their family members in contrast to SFT (where perceived stigma is not explicitly or consistently addressed), we hypothesized that MFT would lead to lower rates of perceived stigma at the end of the intervention and 3 months post-treatment compared with SFT. Finally, we hypothesized that there would be higher levels of social support perceived by family members engaged in MFT.

Methods Procedures and recruitment Consecutive patients with AN admitted to the Eating Disorder Program (EDP) at the Toronto General Hospital, University Health Network in Toronto, Canada, between 2011 and 2014, were approached to participate in this study within the first 3 weeks of treatment. The EDP consists of inpatient and day treatment units that primarily utilize a group therapy modality. The EDP uses a multi-disciplinary approach to treating individuals with severe eating disorders and aims to achieve the following objectives: (i) weight restoration; (ii) normalized eating; (iii) cessation of purging symptoms, and, (iv) relapse prevention. The duration of intensive treatment ranges from 2 to 4 months. Patients may request supportive family counseling to assist with treatment-related issues. Such issues typically include weight gain, symptom control, meal planning for the weekend, and family dynamics that may be impeding the goals of treatment. Participation in the intensive EDP and the initiation of family-based treatment are entirely voluntary. Patients may withdraw from treatment at any time, or may be asked to leave by the clinical team if they are not responding to treatment. Patients meeting DSM-5 (American Psychiatric Association, 2013) criteria for AN who were 17 years of age or over receiving either inpatient or day treatment in the EDP were eligible to Eur. Eat. Disorders Rev. (2015) © 2015 John Wiley & Sons, Ltd and Eating Disorders Association.



was to identify issues that were important to the patient to discuss with their family. The discussions were directed by the patient and not by the therapist. The patients who left the intensive program all had access to outpatient family therapy for a period of 3 months. However, we did not follow the patients to ascertain what kind of treatment (if any) they received after they left our intensive program.

participate in the study. Patients shared information about the study with their family members whom they identified as being involved in supporting them in treatment and recovery. Patients with current family violence were excluded. Interested participants and their nominated family members received information about the study from a research assistant who was not directly involved in the delivery of either intervention.

Assessment measures Assessment of Participants with AN. A digital scale was used to obtain weight in order to calculate the body mass index (BMI). Eating disorder-related psychopathology was assessed using the global score of the Eating Disorder Examination Questionnaire (EDE-Q; Fairburn & Beglin, 1994). Scores on the EDE-Q range from 0 to 6, with higher scores representing increased levels of eating disorder disturbance. BMI and EDE-Q were recorded at the beginning and end of intensive treatment.

Assignment to treatment group and description of interventions Following the informed consent process, patients and their family members were assigned (non-randomly) to single family therapy (SFT, treatment as usual) or multi-family therapy (MFT). The assignment to either MFT or SFT depended on the availability of the treatment. MFT was offered four times a year in a closed group format (additional families were not allowed to join the group once treatment began). A series of groups would begin once four to six families consented to participate in the study. After a group started, families were offered SFT, as it would significantly delay treatment to have them wait for the next MFT group. Patients with other forms of eating disorders (e.g. bulimia nervosa) and their family members also participated in the MFT groups; however, their data is not included in the current study, which focuses exclusively on AN. MFT is a manualized, protocol-driven intervention combining psychoeducation and experiential exercises. MFT was offered on a weekly basis for 90 min per session (one evening a week from 6:30 to 8:00 pm), for a total of eight sessions (12 h total). Two therapists were always present to facilitate MFT. MFT is based on an adaptation of the Cognitive-Interpersonal Maintenance Model of AN (Schmidt & Treasure, 2006; Treasure & Schmidt, 2013; see Table 1 for a detailed description of the content). Two therapists facilitated each MFT series. SFT is individually tailored, based on patient needs, and consists of eight sessions, up to 90 min each (total of 10–12 h). Because SFT occurs in family sessions and not in group sessions, the entire time and focus are on a single family, in contrast to MFT where multiple families share the time. Only one therapist was involved in the provision of SFT which is considered standard practice in the EDP. SFT was not manualized. The purpose of SFT

Assessment of family outcomes Family members were asked to complete a series of questionnaires prior to the start of the family intervention (MFT or SFT), at the end of the intervention, and 3 months post-treatment. The eating disorders symptom impact scale (EDSIS; Sepulveda, Whitney, Hankins, & Treasure, 2008) This scale assesses the impact of caring for people with eating disorders by examining negative appraisals of caregiving within the past month; preliminary data has shown good psychometric properties. The scale contains 24 items that are rated on a fivepoint scale from 0 (never) to 4 (nearly always). The scale can be divided into four subscales: guilt; social isolation; dysregulated behaviour; and nutrition. Items are also used to create an overall sum score (range 0 to 96). Higher scores represent higher levels of negative appraisals. The family questionnaire (FQ; Wiedemann, Rayki, Feinstein, & Hahlweg, 2002) This scale is designed to evaluate expressed emotions in family members of people with mental illness, has been shown to have good construct validity and internal consistency, and has

Table 1 Description of topics of multi-family therapy Sessions 1, 2

3, 4

5, 6

7, 8

Description Introduction and Individual and Family Strengths. Educational information about the group format, structure and norms of the group are reviewed. Facilitators provide educational information about eating disorders, the interpersonal model (processes that may maintain illness behaviours), and the philosophy and structure of the intensive eating disorder program. Various experiential activities are employed to build group cohesion and challenge stigma associated with ED, and blaming and shaming of the affected individual and his/her family. Caregiving Styles. Family members learn about different styles of caring for someone with an eating disorder and how some responses may exacerbate eating disorder behaviours. Intense emotional reactions, accommodation to the illness, and avoidance of illness behaviours are identified as unhelpful responses to supporting people with AN. Meal Support and Strategies to facilitate behavioural change. Individuals in treatment and their families eat a meal together for the purpose of discussing how best to support during and after meals while in treatment and to promote recovery. Strategies for supporting someone with meals, urges to engage in eating disorder behaviours are generated collaboratively with those in treatment and the family members. Relapse Prevention and Ending the group. Individuals and their family members review potential risk factors for slips and relapses. Relapse prevention plans are developed and shared with the group. Participants also discuss what additional resources may be needed to maintain recovery after intensive treatment.

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previously been used in AN (Kyriacou et al., 2008; Sepulveda et al., 2008). Items are scored on a four-point scale from 1 (never, very rarely) to 4 (often). This instrument contains two subscales, each with 10 items: criticism and emotional over-involvement. Subscale scores range from 10 to 40, and higher scores represent higher levels of expressed emotion. Social provisions scale (SPS; Cutrona & Russell, 1987) The SPS is a self-report measure of social support that contains 24 items that are rated on a four-point scale ranging from 1 (strongly disagree) to 4 (strongly agree). Items can be used to create an overall sum score (range from 24 to 96) or can be divided into six subscales: attachment, social integration, reassurance of worth, guidance, opportunity for nurturance, and reliance. Subscale scores range from 4 to 16, and higher scores represent higher levels of social support. This instrument has excellent psychometric properties (Cutrona & Russell, 1987). Devaluation of consumers and consumer families scales (DCCFS; Struening et al., 2001) The DCCFS scales were designed to assess perceived discrimination and stigma. The 15 items are rated on a four-point scale ranging from 1 (strongly agree) to 4 (strongly disagree). The inventory contains two subscales: devaluation of consumer (eight items, subscale scores range from 8 to 32) and devaluation of consumer’s families (seven items, subscale scores range from 7 to 28). Higher scores represent higher levels of perceived discrimination and stigma. We adapted this instrument to make it specific to AN rather than more broadly to mental illness. Beck depression inventory (BDI; Beck, Steer, Ball, & Ranieri, 1996) The BDI is a 21-item self-report instrument used to determine the presence and severity of depressive symptoms. This instrument has been widely used and has been shown to have excellent psychometric properties. Scores range from 0 to 63, and higher scores represent a higher level of depressive symptoms. We also employed an open-ended questionnaire to obtain qualitative feedback from the individual receiving treatment and their family members. Feedback was sought in the following areas: duration of the sessions and the group; content; format used, and suggestions for improving the group. Therapist training and supervision Five family therapists provided the family-based treatments. Although all had extensive experience in eating disorders, there was more variability in the level of training and experience in family therapy. The study therapists included one occupational therapist, one psychiatrist, and three social workers. Family therapists received extensive training in MFT (observed a group, co-facilitated a group with an experienced clinician and reviewed theory and literature about MFT). Ongoing supervision was provided by the PI (GD) to the family therapists delivering MFT to ensure fidelity to the protocol. In SFT, peer supervision was provided. With the exception of one therapist who provided only multi-family therapy, all therapists delivered both treatment modalities.

Results Participants Patients During the timeframe of study recruitment (March 2011 to March 2014), 107 patients with AN were admitted to our EDP and completed at least 4 weeks of treatment. Of those individuals, 45 patients (42%) participated in the study. Reasons for nonparticipation included not meeting inclusion/exclusion criteria for family members (absence of family, family violence), or refusal to participate. A number of reasons for declining to participate were cited, including families living too far away from the hospital, scheduling difficulties, and extensive previous family treatment. Of the 45 AN patients who participated in the study, 44.44% (n = 20) had AN-restrictive subtype, and 55.56% (n = 25) had binge-eating/purging subtype. All patients were female and their ages ranged from 18 to 57 years with a mean age of 26.20 years (SD = 7.36). The duration of the illness ranged from less than 1 year to 25 years with a mean of 7.94 years (SD = 6.14). BMI and EDE-Q score at admission were 15.70 (SD = 1.70) and 4.24 (SD = 1.28), respectively. The majority of patients (73.33%, n = 33) were initially treated within the inpatient program, while 26.67% of patients (n = 12) were treated within the day hospital outpatient program. Patients participated in either SFT (n = 17) or MFT (n = 28). Patients who participated in SFT did not differ on pre-therapy characteristics, ts < 1.72, ps > .05, or in rates of AN subtypes, χ(1) = .78, p > .05, from those who participated in MFT. A subset of patients (11.11%, n = 5) did not complete the treatment program. All patients who prematurely left intensive treatment also withdrew from SFT/MFT. An additional three patients did not complete family therapy. Patients who did not complete family therapy (total of 17.78%, n = 8) did not differ on pre-therapy characteristics from those who completed family therapy (82.22%, n = 37), ts < 1.00, ps > .05 and did not differ in rates of AN subtype, χ(1) = .96, p > .05. Family members A sample of 72 family members consented to participate in the study based on the aforementioned sample of 45 patients. Therefore, an average of 1.60 family members per patient participated in family therapy. The sample of family members was comprised of 36.11% (n = 26) mothers, 31.94% (n = 23) fathers, 20.83% (n = 15) partners, and 11.11% (n = 8) siblings; 52.78% (n = 38) of the sample was male. Family members participated in either SFT (41.67%, n = 30) or MFT (53.33%, n = 42) with the patient. Family members who participated in SFT did not differ on pre-therapy measures from those who participated in MFT, ts < 1.85, ps > .05. Gender and type of family member also did not differ by therapy type, χs < .54, ps > .05. Family members of patients who did not complete intensive treatment and/or family therapy also did not complete family therapy. All family members who completed family therapy attended at least 80% of the family interventions. Family members who completed (84.72%, n = 61) versus did not complete Eur. Eat. Disorders Rev. (2015) © 2015 John Wiley & Sons, Ltd and Eating Disorders Association.



(15.28%; n = 11) family therapy differed on two pre-therapy measures: higher overall social support (M = 77.69, SD = 9.45 vs. M = 71.09, SD = 9.14, t = 2.12, p = .04, d = .71) and higher reliance alliance (M = 13.62, SD = 2.17 vs. M = 12.00, SD = 2.97, t = 2.12, p = .04, d = .62). Completion rates did not differ by gender or therapy type, χs < .89, ps > .05. Statistical analysis Patient analyses were conducted with the 37 patients who completed family therapy (13 SFT; 24 MFT). In this group, 6.31% of patient data observations were missing. Of the total 61 family members who completed family therapy, 73.77% (n = 45) completed post-therapy measures and 45.90% (n = 28) completed 3-month follow-up measures. Family members who completed post-therapy and/or 3-month follow-up measures did not differ on pre-therapy variables from those who did not complete these measures, ts < 1.86, ps > .05. Gender and type of therapy were also not associated with the completion of post-therapy and 3-month follow-up measures, χs < 2.48, ps > .05. Main analyses were conducted with family members who completed family therapy and also completed questionnaires for at least two of the three assessment points (final sample for analysis = 45 family members; 16 SFT and 29 MFT). For this final sample, 12.71% of data observations were missing. To examine change in dependent measures among the two therapy conditions, a series of repeated measures analyses of variance (ANOVA) were conducted. Analyses were controlled for specific family member and/or patient characteristics that were significantly associated with pre-therapy values of dependent variables (see Table 2; Tabachnick & Fidell, 2007). Follow-up ANOVAs were conducted to examine statistically significant interactions between Time (pre-therapy, post-therapy, and threemonth follow-up) and Type of Therapy (SFT and MFT). To address missing data, but to avoid the loss of statistical power associated with listwise deletion, multiple imputation procedures were

employed using SPSS 22.0. Pooled results based on 10 multiple imputations are reported. Only the measure of family member depressive symptoms (BDI) was above established cutoffs for normality (Curran, West, & Finch, 1996). Additional analyses were conducted using log transformations of this measure in order to reexamine the pattern of results.

Results Patients There was a significant Time effect for BMI, F = 263.18, p < .01, η2p = .88, but the Time × Therapy Type interaction effect was not significant, F = 2.18, p = .15, η2p = .06. BMI increased (Mpre = 15.68, SDpre = 1.61; Mpost = 20.29, SDpost = 1.41) over the span of treatment similarly for both of types of family therapy. There was also a significant Time effect for EDE-Q, F = 87.3, p < .01, η2p = .72, but again the Time × Therapy Type interaction effect was not significant, F = .74, p < .40, η2p = .02. EDE-Q decreased (Mpre = 4.05, SDpre = 1.41; Mpost = 2.48, SDpost = 1.22) over the span of treatment similarly for both of types of family therapy. Family members Means and standard deviations of dependent variables are displayed in Table 3, and results of repeated measures ANOVAs are displayed in Table 4. As detailed below, there were significant Time effects for most measures whereas only one significant Time × Therapy Type interaction effect was found. There was a significant Time effect for the sum score as well as all four subscales of negative caregiving appraisals (EDSIS). No Time × Therapy Type interaction effects were found. Family members experienced decreases in negative caregiving appraisals similarly for both of types of family therapy. Post-hoc comparisons showed that the sum score significantly decreased from

Table 2 Zero-order correlations between select pre-therapy variables among final sample of family members (n = 45) 1 1. Gender (of family member) 2. Age (of corresponding patient) 3. AN subtype (of corresponding patient) 4. BMI (of corresponding patient) 5. Illness duration (of corresponding patient) 6. EDE-Q (of corresponding patient) 7. Overall negative appraisals of caregiving (EDSIS) 8. Criticism (FQ) 9. Over-involvement (FQ) 10. Overall social support (SPS) 11. Consumer stigma (DCCFS) 12. Consumer’s family stigma (DCCFS) 13. Depressive symptoms (BDI)

— .24 .08 .14 .07 .15 .14 .04 .34* .30 .06 .03 .01

2 — .26 .11 .57** .14 .25 .16 .05 .27 .16 .21 .23

3

— .31* .14 .48** .20 .05 .04 .06 .36* .45** .29

4

5

6

— .04 .21 .07 .22 .11 .23 .37* .38* .11

— .11 .18 .48* .08 .10 .05 .02 .22

— .20 .02 .04 .01 .23 .29 .19

7

— .41** .66** .16 .21 .20 .38*

8

— .38* .01 .28 .16 .12

9

— .01 .18 .10 .57**

10

11

12

— .05 .10 .25

— .74** .22

— .20

Note. *p < .05, **p < .01. Gender is scored: 1 = women, 2 = men; AN subtype is scored: 1 = restricting type, 2 = binge-eating/purging type; AN = anorexia nervosa; BMI = body mass index; EDE-Q = Eating Disorder Examination Questionnaire; EDSIS = Eating Disorder Symptom Impact Scale; FQ = Family Questionnaire; SPS = Social Provision Scale; DCCFS = Devaluation of Consumer and Consumer Families; BDI = Beck Depression Inventory.

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Multi-Family Therapy for Anorexia Nervosa Table 3 Means and standard deviations of dependent variables of family members SFT (n = 16) Pre-therapy M (SD) Negative appraisals of caregiving (EDSIS) Overall impact 35.06 Guilt 8.64 Social isolation 5.13 Dysfunctional behaviour 3.31 Nutrition 18.04

(11.58) (3.92) (3.05) (3.55) (5.62)

Post-therapy M (SD)

MFT (n = 29) Follow-up M (SD)

18.18 (10.06) 5.49 (3.92) 3.32 (3.15) .95 (1.38) 8.41 (6.10)

13.97 3.76 2.20 1.57 6.81

(7.20) (2.58) (2.34) (1.63) (3.81)

Pre-therapy M (SD)

35.13 10.12 4.62 4.57 15.69

(15.11) (5.24) (3.49) (4.56) (6.13)

Post-therapy M (SD)

22.28 6.67 3.64 2.41 9.43

(14.70) (4.99) (3.84) (2.69) (6.47)

Follow-up M (SD)

18.21 6.11 3.17 2.03 6.98

(13.26) (4.73) (2.69) (2.66) (5.21)

Expressed emotion (FQ) Criticism Over-involvement

16.80 (6.20) 27.06 (4.28)

15.08 (4.25) 24.23 (4.37)

12.91 (2.21) 19.52 (3.30)

19.92 (4.73) 26.17 (4.40)

16.46 (4.69) 23.97 (5.20)

14.38 (4.18) 21.82 (5.42)

Social support (SPS) Overall Attachment Social integration Reassurance of worth Guidance Nurturance Reliance alliance

78.22 12.18 13.10 13.29 13.34 11.69 14.18

77.41 12.59 12.89 13.13 13.21 11.95 13.68

75.77 12.07 12.74 12.82 12.84 11.83 13.53

76.47 12.31 12.69 13.02 12.76 12.55 13.14

78.40 12.79 12.78 13.47 13.41 12.58 13.20

77.07 12.32 12.98 13.32 12.98 12.49 12.93

Stigma (DCCFS) Consumer Family

14.94 (3.30) 13.41 (2.62)

15.46 (2.89) 13.38 (2.65)

14.99 (2.06) 14.04 (1.97)

15.93 (3.14) 14.25 (3.87)

15.64 (3.02) 14.84 (2.57)

15.33 (2.49) 14.05 (3.32)

Depressive symptoms (BDI)

10.50 (7.54)

7.52 (7.52)

3.77 (2.72)

12.64 (9.75)

8.68 (9.92)

6.12 (8.34)

(7.07) (2.09) (1.57) (1.60) (1.90) (2.67) (1.56)

(6.27) (1.55) (1.51) (1.26) (1.79) (2.08) (1.37)

(5.10) (1.68) (1.37) (1.18) (1.48) (1.51) (1.56)

(9.41) (2.49) (2.09) (2.07) (1.90) (2.46) (1.77)

(8.77) (2.45) (1.90) (1.75) (1.75) (2.01) (1.83)

(86.18) (23.70) (1.64) (1.88) (1.94) (2.48) (1.64)

Note. Follow-up = 3-month follow-up; AES = Accommodation and Enabling Scale; EDSIS = Eating Disorder Symptom Impact Scale; FQ = Family Questionnaire; SPS = Social Provision Scale; FAD = Family Assessment Device; DCCFS = Devaluation of Consumer and Consumer Families; BDI = Beck Depression Inventory.

pre-therapy to post-therapy and also from post-therapy to 3-month follow-up (ps < .05). Post-therapy and 3-month follow-up scores were significantly lower than pre-therapy scores for all four subscales (ps < .05), but post-therapy and follow-up scores did not significantly differ (ps > .05). In regards to expressed emotion (FQ), there was a significant Time effect, but no Time × Therapy Type interaction effect, for the criticism subscale. Family members experienced decreases in criticism similarly for both types of family therapy. Post-hoc comparisons showed that criticism significantly decreased from pretherapy to post-therapy and also from post-therapy to 3-month follow-up (ps < .05). In contrast, there was a significant Time effect and a significant Time × Therapy Type interaction effect for the over-involvement subscale. Post-hoc analyses first determined that there was a significant Time effect, F = 5.68, p = .02, η2p = .12, but no Time × Therapy Type interaction effect, F = .36, p = .55, η2p = .01, when examining pre- and post-therapy overinvolvement scores, exclusively. Over-involvement significantly decreased from pre-therapy to post-therapy similarly for both types of therapy. Post-hoc analyses next determined that there was a significant Time effect, F = 4.23, p < .05, η2p = .09, but no Time × Therapy Type interaction effect, F = 2.75, p = .10, η2p = .06, when examining post-therapy and 3-month follow-up scores, exclusively. Over-involvement significantly decreased from post-therapy to 3-month follow-up similarly for both types of therapy.

No Time or Time × Therapy Type effects were found for social support (SPS) and stigma (DCCFS). There was a significant Time effect for family member depressive symptoms (BDI), but no Time × Therapy Type interaction effect. Family members experienced decreases in depressive symptoms similarly for both types of family therapy. Post-hoc comparisons showed that depressive symptoms significantly decreased from pre-therapy to post-therapy and also from posttherapy to 3-month follow-up (ps < .05). As the measure of depressive symptoms was skewed and kurtotic at 3-month followup, analyses were re-run using transformed variables. The same pattern of results was found; Time effect, F = 6.98, p < .01, η2p = .14; Time × Therapy Type interaction effect, F = .27, p > .05, η2p < .01. Acceptability and feasibility of MFT to patients and family members: A subset of the 31 participants (patients (n = 8) and their family members (n = 23) provided qualitative feedback on their experiences of MFT, including the format, content, and duration. Although patients initially expressed reluctance to invite their family members to engage in a group-based intervention, all of them reported that they and their family members appreciated hearing the experiences of others who were struggling with similar issues. Patient and family participants also noted that the length of sessions and duration of the intervention were Eur. Eat. Disorders Rev. (2015) © 2015 John Wiley & Sons, Ltd and Eating Disorders Association.



Table 4 Summary of analysis of variance results for family members Time Scale

F (p)

Time × treatment condition

Partial η

2

F (p)

Partial η

Negative appraisals of caregiving (EDSIS) Overall impact 47.66 (